Litigation After Nasal Plastic Surgery

Introduction: Esthetic surgeries are among the commonest medical procedures in the world nowadays; and as statistics declare, there has been a rapid increase in the rate of rhinoplasty during the recent years. Hence, as the number of cosmetic surgeries rises, the increment in the number of physicians being sued is quite inevitable; either due to complication in rhinoplasties or even inability to fulfill the patients’ expectations. This article aims to clarify the aspects of causes leading to these legal claims. Materials and Methods: We designed a retrospective study according to the available files in the Iranian Organization for Forensic Medicine in which physicians were sued for the outcomes of rhinoplasty through the years 2004 to 2010. In addition, information on the patients’ demographic data, surgeons’ specialty and experience, and method of anesthesia were also collected. Results: One hundred twenty six patients entered the study among which 77 (61%) were female and 49 (39%) male. Mean age was obtained as 26.9 ± 7.7yrs. Up to 79.4% of patients had complaints concerning the cosmetic outcomes, 39.7% with respiratory and 4.8% with olfactory problems. The reason to sue the physician had a significant relationship with the patients’ age and sex, and also with the surgeons’ experience. Conclusion: There are multiple reasons impelling the patients to sue surgeons after rhinoplasty, some are related to physicians’ malpractice and some to the patients’ social and personal circumstances.


Introduction
Surgeries for cosmetic purposes are now considered as one of the commonest medical procedures worldwide. Cosmetic surgeries keep up with the world's development, and according to statistics, over 6 million facial plastic surgeries have been performed in the United States during the year 2007; this vast number shows an 8% increase compared to year 2006, and 460% increase compared to its previous decade (1). Although there is no precise statistics on the amount of plastic surgeries taking place in Iran, it is quite assumable that requests for plastic surgeries (rhinoplasty as a major component), have the same increasing rate as the world has.
As the number of operations rises and patients compare the works of various surgeons, and as the outcomes of rhinoplastic surgeries are supposed to satisfy the patients' expectations and the patients desire to have a perfect nose in both cosmetics and physiological aspects.
Inevitably, the surgery may not result in the patient's desired nose, and impel the patients to sue physicians due to undesirable outcomes. Among cosmetic surgeries leading to sue a physician in developed countries, rhinoplasty accounts for about 22% of cases (2). Considering that rhinoplasty is ranked as the fifth most common plastic surgery in these countries, in Iran it is already the commonest facial plastic surgery taking place; therefore, rhinoplasty complications are thought to be the most popular legal claims in this category.
Reasons, from which these complaints have been raised are related to diversity in anatomic structures of patients' noses, inappropriate surgical techniques, inefficient surgeons' experience and skills, and the unique nature of all plastic surgeries, which finally precipitates in patients' dissatisfaction (3). On the other hand, the financial gain has encouraged non-ENT surgeons to commit such surgeries too. In this respect, we decided to investigate the possible reasons leading to suing surgeons by those patients having undergone rhinoplasty in the recent years.

Study Subjects
A retrospective cross-sectional study was designed, in which one hundred twenty six case files were reviewed. The files were selected among those cases which led to sue physicians after rhinoplasty, and were referred to the Iranian Organization for and/or unsatisfactory outcomes after rhinoplasty; and all fulfilled the required data for this study.

Inclusion Criteria
Patients who had undergone rhinoplasty, were not satisfied with their surgery outcomes, and had sued their physician.

Exclusion Criteria
Patient files lacking information required for this study and those who had refused to sue the physician were excluded from this study.

Ethical Approval
Since this is a descriptive study and no intervention was made neither to case files nor to patients and physicians; ethical considerations were aimed on keeping the confidentiality of both patients' and physicians' personal data.
Variables -Demographic data: The age (while undergoing surgery) and sex of suing patients were obtained from their files.
-Reason leading to physician's sue: There were thirteen district issues that complaints were raised from, they were: 1. problems with respiration, 2. problems with olfaction, 3. Cosmetics, 4. Asymmetry, 5. septal perforation, 6. ophthalmic complications, 7. Headaches, 8. Voice changes, 9. nasal discharge, 10. burns by electric cutter, 11. unilateral paresthesia, 12. problems with audition, and 13. patients' death. Although all the patients had undertaken the surgery for cosmetic purposes, but the reason they claimed to sue the physician was not necessarily the cosmetic outcomes.
-Surgeon's experience The surgeon's experience was defined as the sum of years he/she had been doing surgery till the claims due, according to this, surgeons were categorized into four groups: residents, low experienced (less than 5 years of experience), intermediately experienced (5 to 10 years of experience) and high experienced (more than 5 years of experience).
-Surgeon's specialty The type of residency programs which the surgeons were trained in was also taken into account; therefore they were categorized into three groups: Plastic surgeons, ENT surgeons and other specialties.
-Patient's death We also investigated the files to find whether rhinoplasty has precipitated in patients' death.
-Method of anesthesia Either of these two methods of anesthesia was used for the patients: general anesthesia or local anesthesia.
-Number of times the patient had undergone rhinoplasty The files were investigated to know whether the first time surgery precipitated in the undesirable outcome or the following surgeries were the cause.

Statistical Method
Data was analyzed using Chi-Square test and T-test by applying SPSS version 11.5. The values were evaluated using descriptive statistical methods (mean ± SD) and the results were considered as significant at P<0.05.

Results
Among 126 patients having entered the study, 77 (61%) were female and 49 (39%) were male. Mean age was calculated as 26.9 ± 7.7 years with the maximum of 54, and the minimum of 17 years.    The type of specialty in which the surgeon was trained, was also investigated.  Method of anesthesia, number of times the patient had undergone surgery and the surgeon's specialty were not significantly related to the reasons to sue. Also, because of the fact that the total number of surgeries by different specialties is unknown, the ratios of litigation between different surgeons are ambiguous. Since nasal plastic surgery is a highly litigated area of otolaryngology, therefore precise patient selection and consulting are greatly recommended before surgery planning (7)(8)(9).

Conclusion
What this study suggests is that the process which leads suing a surgeon by the patient is a multi factorial issue; therefore some cases are caused by physicians' malpractice, and some are dependent on the patients' personal and social characteristics.
The thing that seems necessary for every physician is to describe all medical, personal and social aspects of esthetic surgeries beside the possible complications that may cause irreversible damage to his/her face integrity. Despite the fact that almost every physician does so, the attitude of the patient to this kind of surgery should be evaluated, because he/she must be fully convinced that rhinoplasty is never meant to fulfill all his/her ideals for a perfect nose.